Life Support May End Too Soon After Brain Injury

Action Points

Explain that large variations in mortality rates from severe traumatic brain injury appear to be partly due to how centers treat withdrawal of life support.

Note that the proportion of deaths related to withdrawal of life-sustaining therapies ranged from 45% to 86.8% in the analysis.

Large variations in mortality rates from severe traumatic brain injury appear to be partly due to how centers treat withdrawal of life support, researchers found.

Mortality rates for these cases at Canadian trauma centers ranged from just 10.8% to as high as 44.2%, Alexis F. Turgeon, MD, MSc, of Laval University in Quebec, and colleagues reported online in CMAJ.

More than 20% of the variation was estimated to be based on the hospital alone, as it was affected by, and associated with, the rates and timing of withdrawal of life-sustaining therapy in the analysis.

Given the the limited accuracy of prognostic indicators for severe traumatic brain injury patients, the researchers urged caution in consideration of early withdrawal of life support.

"Communication with families needs to begin early, occur frequently, and deliver a consistent message to achieve optimal outcomes and timing of any withdrawal of support," an accompanying commentary added.

But commentators David H. Livingston, MD, Anne C. Mosenthal, MD, both of New Jersey Medical School in Newark, noted that these results point to physician practice and the culture of medical centers as playing perhaps just as strong a role as patient and family preferences.

The researchers retrospectively studied 720 randomly-selected severe traumatic brain injury patients from those seen over a two-year period at six Canadian level-one trauma centers.

The majority of these injuries arose from motor vehicle collision (55.5%), followed by falls (29.7%) and assault (7.5%) as causes of traumatic brain injury.

The proportion of deaths related to withdrawal of life-sustaining therapies ranged from 45% to 86.8% in the analysis for an overall average of 70.2%.

Of these deaths after withdrawal of life support, 45.6% occurred within the first three days of care. And 64% of deaths within three days of ICU admission in these cases were associated with life-support withdrawal.

The researchers called these rates "of great clinical relevance" because severe traumatic brain injury patients are often young with little in the way of comorbidity.

"In some instances, this [three day window] may be too early for accurate neuroprognostication," they warned in the paper.

Overall mortality and deaths following withdrawal of life support both varied by center (P≤0.001).

Statistical models indicated that "baseline risk factors account for little variation in the incidence of withdrawal of life-sustaining therapy and that centre accounts for more systematic variation than baseline risk factors," Turgeon's group noted in the paper.

Reasons for the decision to withdraw life-sustaining therapy varied significantly between centers as well (P<0.0001 for difference).

The most common reasons given were:

A poor chance of survival according to the medical team (54.4%)

A prognosis incompatible with the patient's wishes, as indicated by the family (33.8%)

A poor long-term neurologic prognosis, as indicated by the medical team (28.5%)

The researchers cautioned that their retrospective study couldn't determine long-term outcomes or functional outcomes and may have been impacted by referral bias that would affect mortality rates across centers.

Another limitation was that reliance on patient medical records may have underestimated incidence of withdrawal of life support.

The study was supported in part by the Fondation de l'Hôpital de l'Enfant-Jésus.

Turgeon reported receiving a research career award from the Fonds de recherche Santé Québec.

The researchers reported having no conflicts of interest to disclose.

Livingston and Mosenthal reported having no conflicts of interest to disclose.

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